School Sports Pre‐Participation Examination – Part 1: Student or Parent Completes Revised May 2010 NAME: BIRTHDATE: / ADDRESS: PHONE: ( ) Athlete and Parent/Guardian: Please review all questions and answer them to the best of your ability. Explain any YES answers on back. Medical Provider: Please review with the athlete details of any positive answers. YES NO Don’t Know / 1.
Has anyone in the athlete’s family died suddenly before the age of 50 years? 2.
Has the athlete ever passed out during exercise or stopped exercising because of dizziness or chest pain? 3.
Does the athlete have asthma (wheezing), hay fever, other allergies, or carry an EPI pen? 4.
Is the athlete allergic to any medications or bee stings? 5.
Has the athlete ever broken a bone, had to wear a cast, or had an injury to any joint? 6.
Has the athlete ever had a head injury or concussion? 7.
Has the athlete ever had a hit or blow to the head that caused confusion, memory problems, or prolonged headache? 8.
Has the athlete ever suffered a heat‐related illness (heat stroke)? 9.
Does the athlete have a chronic illness or see a physician regularly for any particular problem? 10. Does the athlete take any prescribed medicine, herbs or nutritional supplements? 11. Does the athlete have only one of any paired organ (eyes, kidneys, testicles, ovaries, etc.)? 12. Has the athlete ever had prior limitation from sports participation? 13. Has the athlete had any episodes of shortness of breath, palpitations, history of rheumatic fever or tiring easily? 14. Has the athlete ever been diagnosed with a heart murmur or heart condition or hypertension? 15. Is there a history of young people in the athlete’s family who have had congenital or other heart disease: cardiomyopathy, abnormal heart rhythms, long QT or Marfan's syndrome? (You may write "I don't understand these terms" and initial this item, if appropriate.) 16. Has the athlete ever been hospitalized overnight or had surgery? 17. Does the athlete lose weight regularly to meet the requirements for your sport? 18. Does the athlete have anything he or she wants to discuss with the physician? 19. Does the athlete cough, wheeze, or have trouble breathing during or after activity? 20. Are you unhappy with your weight? 21. FEMALES ONLY a.
When was your first menstrual period? b.
When was your most recent menstrual period? c.
What was the longest time between menstrual periods in the last year? Parent/Guardian’s Statement: I have reviewed and answered the questions above to the best of my ability. I and my child understand and accept that there are risks of serious injury and death in any sport, including the one(s) in which my child has chosen to participate. I hereby give permission for my child to participate in sports / activities. I hereby authorize emergency medical treatment and/or transportation to a medical facility for any injury or illness deemed urgently necessary by a registered athletic trainer, coach, or medical practitioner. I understand that this sports pre‐participation physical examination is not designed nor intended to substitute for any recommended regular comprehensive health assessment. I hereby authorize release of these examination results to my child's school. Signed: Date: Parent/Guardian ORS 336.479, Section 1 (3) "A school district shall require students who continue to participate in extracurricular sports in grades 7 through 12 to have a physical examination once every two years." Section 1(5) “Any physical examination required by this section shall be conducted by a (a) physician possessing an unrestricted license to practice medicine; (b) licensed naturopathic physician; (c) licensed physician assistant; (d) certified nurse practitioner; or a (e) licensed chiropractic physician who has clinical training and experience in detecting cardiopulmonary diseases and defects.” Oregon School Activities Association Forms – Physical Examination‐2010 Revised: 05/10 ‐ 129 ‐ 2012‐2013 Handbook School Sports Pre‐Participation Examination – Part 2: Medical Provider Completes Revised May 2010 NAME: / Height: Vision: R 20/ Weight: % Body Fat (optional): L 20/ Corrected: Y N MEDICAL Pupils: Equal NORMAL BIRTHDATE: / Pulse: BP: ____/____ (____/____, ____/____) Unequal Rhythm: Regular _____ Irregular _____ ABNORMAL FINDINGS
INITIALS*
Appearance Eyes / Ears / Nose / Throat Lymph Nodes Heart: Pericardial activity 1 & 2 heart sounds Murmurs Pulses: brachial / femoral Lungs Abdomen Skin st
nd
MUSCULOSKELETAL Neck Back Shoulder / arm Elbow / forearm Wrist / hand Hip / thigh Knee Leg / ankle Foot * Station‐based examination only CLEARANCE Cleared Cleared after completing evaluation / rehabilitation for: Not cleared for: Reason: Recommendations: Name of Medical Provider: (print or type) Date: Address: Phone: ( ) Signature of Medical Provider: ORS 336.479, Section 1 (3) "A school district shall require students who continue to participate in extracurricular sports in grades 7 through 12 to have a physical examination once every two years." Section 1(5) “Any physical examination required by this section shall be conducted by a (a) physician possessing an unrestricted license to practice medicine; (b) licensed naturopathic physician; (c) licensed physician assistant; (d) certified nurse practitioner; or a (e) licensed chiropractic physician who has clinical training and experience in detecting cardiopulmonary diseases and defects.” Oregon School Activities Association ‐ 130 ‐ Forms – School Sports Pre‐Participation Examination Revised: 05/10 2012‐2013 Handbook SUGGESTED EXAM PROTOCOL FOR THE PHYSICIAN Revised May 2010 MUSCULOSKELETAL Have patient: 1. Stand facing examiner 2. Look at ceiling, floor, over shoulders, touch ears to shoulders 3. Shrug shoulders (against resistance) 4. Abduct shoulders 90 degrees, hold against resistance 5. Externally rotate arms fully 6. Flex and extend elbows 7. Arms at sides, elbows 90 degrees flexed, pronate/supinate wrists 8. Spread fingers, make fist 9. Contract quadriceps, relax quadriceps 10. “Duck walk” 4 steps away from examiner 11. Stand with back to examiner 12. Knees straight, touch toes 13. Rise up on heels, then toes To check for: AC joints, general habitus Cervical spine motion Trapezius strength Deltoid strength Shoulder motion Elbow motion Elbow and wrist motion Hand and finger motion, deformities Symmetry and knee/ankle effusion Hip, knee and ankle motion Shoulder symmetry, scoliosis Scoliosis, hip motion, hamstrings Calf symmetry, leg strength MURMUR EVALUATION – Auscultation should be performed sitting, supine and squatting in a quiet room using the diaphragm and bell of a stethoscope. Auscultation finding of: 1. S1 heard easily; not holosystolic, soft, low‐pitched 2. Normal S2 3. No ejection or mid‐systolic click 4. Continuous diastolic murmur absent 5. No early diastolic murmur 6. Normal femoral pulses (Equivalent to brachial pulses in strength and arrival) Rules out: VSD and mitral regurgitation Tetralogy, ASD and pulmonary hypertension Aortic stenosis and pulmonary stenosis Patent ductus arteriosus Aortic insufficiency Coarctation MARFAN’S SCREEN – Screen all men over 6’0” and all women over 5’10” in height with echocardiogram and slit lamp exam when any two of the following are found: 1. Family history of Marfan’s syndrome (this finding alone should prompt further investigation) 2. Cardiac murmur or mid‐systolic click 3. Kyphoscoliosis 4. Anterior thoracic deformity 5. Arm span greater than height 6. Upper to lower body ratio more than 1 standard deviation below mean 7. Myopia 8. Ectopic lens CONCUSSION ‐‐ When can an athlete return to play after a concussion? After suffering a concussion, no athlete should return to play or practice on the same day. Previously, athletes were allowed to return to play if their symptoms resolved within 15 minutes of the injury. Studies have shown that the young brain does not recover that quickly, thus the Oregon Legislature has established a rule that no player shall return to play following a concussion on that same day and the athlete must be cleared by an appropriate health care professional before they are allowed to return to play or practice. Once an athlete is cleared to return to play they should proceed with activity in a stepwise fashion to allow their brain to readjust to exertion. The athlete may complete a new step each day. The return to play schedule should proceed as below following medical clearance: Step 1: Light exercise, including walking or riding an exercise bike. No weightlifting. Step 2: Running in the gym or on the field. No helmet or other equipment. Step 3: Non‐contact training drills in full equipment. Weight training can begin. Step 4: Full contact practice or training. Step 5: Game play. If symptoms occur at any step, the athlete should cease activity and be re‐evaluated by a health care provider. 581‐021‐0041 Form and Protocol for Sports Physical Examinations The State Board of Education adopts by reference the form entitled "School Sports Pre‐Participation Examination May 2010" that must be used to document the physical examination and sets out the protocol for conducting the physical examination. Medical providers conducting physicals on or after June 30, 2010 must use the form dated May 2010. NOTE: The form can be found on the Oregon School Activities Association (OSAA) Website www.osaa.org. Stat. Auth: ORS 326‐051 Stats. Implemented: ORS 336.479 Hist.: ODE 24‐2002, f. & cert. ef. 11‐15‐02; ODE 29‐2004(Temp), f. & cert. ef. 9‐15‐04 thru 2‐25‐05; ODE 4‐2005, f. & cert. ef. 2‐14‐05 Oregon School Activities Association Forms – Physical Examination‐2010 Revised: 05/10 ‐ 131 ‐ 2012‐2013 Handbook